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Fax completed prior authorization request form to 8773098077 or submit Electronic Prior Authorization through CoverMyMeds or Subscripts. PHOSPHINE (implant) PRIOR AUTHORIZATION Formation authorization
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The opioid-dependence-treatments-probuphine-request-form-04-10-18-pa is a form used to request the Probuphine implant, which is a treatment for opioid dependence. It is provided in an accessible PDF format for easy filling and submission.
Healthcare providers and institutions that are authorized to prescribe or administer opioid dependence treatments are required to file this request form.
To fill out the form, download the accessible PDF, provide accurate patient information, treatment history, and any necessary signatures, then submit the completed form as per the guidelines provided.
The purpose of the form is to facilitate the approval and provision of the Probuphine implant as a treatment for individuals with opioid dependence.
The form requires reporting patient identification details, medical history, previous treatment results, and healthcare provider information.
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